báo cáo sinh học:" Conflicting priorities: evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward" pptx

BioMed Central Page 1 of 14 (page number not for citation purposes) Human Resources for Health Open Access Research Conflicting priorities: evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward Rachel N Manongi 1 , Fortunata R Nasuwa 2 , Rose Mwangi 2 , Hugh Reyburn 2,3 , Anja Poulsen 2,4 and Clare IR Chandler* 3 Address: 1 Community Health Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, 2 Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, 3 Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK and 4 Department of International Health, University of Copenhagen, Copenhagen, Denmark Email: Rachel N Manongi - rmanongi@yahoo.co.uk; Fortunata R Nasuwa - mankaray@yahoo.com; Rose Mwangi - mwangirose2000@yahoo.co.uk; Hugh Reyburn - hugh.reyburn@lshtm.ac.uk; Anja Poulsen - anja@dadlnet.dk; Clare IR Chandler* - clare.chandler@lshtm.ac.uk * Corresponding author Abstract Background: Patient, or parent/guardian, satisfaction with health care provision is important to health outcomes. Poor relationships with health workers, particularly with nursing staff, have been reported to reduce satisfaction with care in Africa. Participatory research approaches such as the Health Workers for Change initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. We evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania. Methods: The intervention consisted of six workshops, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Parental satisfaction with nursing care was measured with 288 parents before and six weeks after the workshops, by means of an adapted Picker questionnaire. Two focus-group discussions were held with the workshop participants six months after the intervention. Results: During the workshops, nurses demonstrated awareness of poor relationships between themselves and mothers. To tackle this, they proposed measures including weekly meetings to solve problems, maintain respect and increase cooperation, and representation to administrative forces to request better working conditions such as equipment, salaries and staff numbers. The results of the parent satisfaction questionnaire showed some improvement in responsiveness of nurses to client needs, but overall the mean percentage of parents reporting each of 20 problems was not statistically significantly different after the intervention, compared to before it (38.9% versus 41.2%). Post-workshop focus-group discussions with nursing staff suggested that nurses felt more empathic towards mothers and perceived an improvement in the relationship, but that this was hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs. Conclusion: The intended outcome of the intervention was not met. The priorities of the intervention – to improve nurse-parent relationships – did not match the priorities of the nursing staff. Development of awareness and empathy was not enough to provide care that was satisfactory to clients in the context of working conditions that were unsatisfactory to nurses. Published: 23 June 2009 Human Resources for Health 2009, 7:50 doi:10.1186/1478-4491-7-50 Received: 10 June 2008 Accepted: 23 June 2009 This article is available from: http://www.human-resources-health.com/content/7/1/50 © 2009 Manongi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 2 of 14 (page number not for citation purposes) Background Patient, parent or guardian satisfaction with health care is now seen as central to the performance of health services [1]. Satisfaction with health care delivery affects likeli- hood of compliance with treatment [2], likelihood of absconding during admission and willingness to pay for treatment [3], as well as overall usage [4] and demand for services [5,6]. Interpersonal aspects of care have been identified as key to community satisfaction with health services in many set- tings [7-9], and may even outweigh the importance of per- ceived technical competence. For example, among community members in Tanzania, "receiving the 'right' drugs from a rude health worker represented a poorer quality of care than receiving the same drugs from a polite worker, and perhaps was even poorer than receiving the 'wrong' drugs from a polite worker" [10]. Improving usage of health facilities by communities and quality of care delivered by health workers is essential if targets for better health are to be achieved in developing countries [11]. Improving interactions between health workers and clients, particularly nursing staff, who in many settings are the face of health care delivery, is key to increasing satisfaction with health care [12]. Participatory research, a popular approach to behaviour change, is a process whereby insiders collaborate with outside researchers as equal partners to explore current action with the intention of generating change [13]. A series of workshops has been designed based on this approach with the aim of improving health worker-client relationships in developing countries. The workshop series is called Health Workers for Change (HWC) and encourages health workers to critically exam- ine the way they relate to clients, with a particular gender emphasis, and the factors that influence this relationship. The workshops are designed to empower and transform participants, motivating them to take constructive action [14]. The workshops are described in a manual published by the World Health Organization [15]. The series has under- gone evaluation for acceptability in four different African settings [16] and evaluation for effectiveness in seven dif- ferent primary health care settings. It was found to result in positive changes in terms of reduced time spent at facil- ities by clients at five sites; improved interactions between health workers and clients at four sites; and improved interactions between staff at four sites where problems were discussed more openly and staff took the initiative to solve problems themselves [17]. The effectiveness of the workshop series as an intervention for nurses working in a hospital inpatient setting has not yet been explored. Study objective We aimed to assess the ability of the HWC workshop series to improve the quality of the relationship between nurses and parents on the paediatric ward of a regional hospital in Tanzania where low quality of technical and interpersonal care had previously been reported as part of an assessment of paediatric care at 13 hospitals in north- east Tanzania [18,19]. In addition to the impact of the intervention, our study evaluated the process of the inter- vention and ventured to understand factors affecting the intended outcomes of the intervention. Methods Study design The study evaluated the effect of a workshop intervention, Health Workers for Change, on nurse-parent relationships on a paediatric ward in a busy regional hospital in Tanza- nia. The evaluation used before-and-after questionnaires with parents/guardians and two after-intervention focus groups with nursing aides and trained nurses to assess the effect of the intervention. Study setting The intervention was implemented and evaluated in a regional hospital serving more than 110 000 outpatients and 20 000 inpatients each year (data from 2007 hospital records). The hospital has 13 wards, including two linked wards for paediatrics, wards 4A and 4B, with a daily aver- age of 50 and 17 paediatric inpatients staying at each, respectively. The hospital employs 427 staff members, of whom 142 (33%) are trained nurses and 188 (44%) are nursing attendants. In all, 31 nursing staff worked on the paediat- ric wards at the time of the study; 13 were trained nurses (they had completed four years' training as nurse mid- wives or nursing officers) and 18 were nurse attendants (they had completed one year of training pre-service). The median time in post was 21 years (range 10 months- 37 years) and median duration on the paediatric ward was seven years (range nine months-22 years). The average sal- ary of nursing attendants was USD 80, with trained nurses earning an average of USD 290. The area has low and sea- sonal malaria endemicity. The study took place during the peak malaria season from May to July 2007. Study population The study population consisted of all nurses on the paedi- atric ward. Twenty-nine of these nurses participated in the workshops and 24 in the post-workshop FGDs, six months later. The nurses were assessed for interpersonal Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 3 of 14 (page number not for citation purposes) care by two populations of parents: 144 parents with chil- dren on the ward prior to the workshops and a further 144 with children on the ward six weeks after the workshops. As most children on paediatric wards are accompanied by mothers, we refer to all parents/guardians as mothers in this paper. Workshops The workshops followed the format set out in the Health Workers for Change manual[15]. This involved six work- shops that took place over a period of three weeks, with two, two-hour sessions per week. The workshops addressed the following topics: (1) "Why I am a health worker", (2) "How do our clients see us?", (3) "women's status in society", (4) "unmet needs", (5) "overcoming obstacles at work", and (6) "solutions". The hospital and regional administrations were consulted and gave support to the project. Nurses of all levels, including nursing attendants, who were working on the paediatric ward were invited by letter to attend an initial meeting to introduce the workshops and to arrange con- venient dates and times for the workshops. The work- shops took place in a self-contained building at the hospital site. Participants were provided with refresh- ments and a return fare from their home on the days of the workshops. Two researchers ran each of the work- shops (RM & FN), which included various exercises such as role plays, paper-and-pen small-group exercises, narra- tives and discussions. The workshops were conducted in Kiswahili, with notes on the proceedings and verbatim quotes recorded by hand. All participants gave informed consent to participate and were aware that the process was being evaluated. Data collection methods Parent satisfaction questionnaire survey Questionnaire design We designed a parent satisfaction questionnaire for use before and after the workshops to evaluate their effect. There is no standardized patient satisfaction measure- ment tool for developing countries. Picker survey instruments for assessing patient experi- ences of health care are gold standard surveys widely used across the developed world [20]. The Picker adult inpa- tient questionnaire, comprising 40 items, has been reduced to a core set of items that have been validated for use across different settings, termed the Picker Patient Experience 15, or PPE-15 [21]. We adapted the reduced questionnaire for nursing care for inpatient paediatrics with additional context-specific questions developed from the focus-group discussions with mothers. Following Jenkinson et al. [21], we conceptualized the questionnaire in terms of each item as a problem (Table 1). Each was then phrased as a question, with a range of possible responses, for example: Did nurses give you enough information about your child's illness in a way that you could understand? [1] Yes, definitely [2] Yes, to some extent [3] No The answers for each question could then be given a binary value of the presence or absence of a problem. The resulting survey was translated and back-translated into Kiswahili by a team of translators. A copy of the full ques- tionnaire is available from the authors. Content validity of the questionnaire was strengthened by the initial FGD results and construct validity was meas- ured using the discriminance, or the "extreme groups" method (the extent to which the questionnaire produces results that concur with the underlying theoretical con- struct) [22]. Reliability was measured with Cronbach's coefficient, showing the average correlation among items in the questionnaire. Questionnaire sample We used data from a 2005 patient satisfaction study at this hospital, when 36% of 42 mothers interviewed stated that they found the nursing staff to be polite or helpful [18], to estimate the sample size needed to detect an increase in satisfaction of 50% with 80% power and 95% confidence. The result was 143 mothers each before and after the workshops, allowing for 10% unusable data. The primary parent or guardian of every child under five years of age admitted to the paediatric ward within 24 hours of the time of the survey was eligible for inclusion in the survey sample. Interview procedure With the permission of the staff on the ward, parents of eligible children were approached and, after oral informed consent was obtained, were interviewed by an experienced researcher (FN) in a secluded area of the ward. Analysis Data were double-entered into Microsoft Access 2007 and analysed by means of STATA 10 (Statacorp, Texas, United States of America). Analysis of the questionnaire used a dichotomous problem score, indicating either the pres- Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 4 of 14 (page number not for citation purposes) ence or absence of a problem, with a simple additive scor- ing algorithm, following Jenkinson et al. [21]. Z-tests were used to compare data before and after the workshops, including demographic variables, individual problems identified by respondents and additive problem scores. Focus group discussion Conduct of FGDs Two FGDs with (1) nurse attendants and (2) trained nurses on the paediatric ward were conducted six months after the first post-workshop visit. The FGDs were con- ducted by one facilitator (RM, medical doctor and social scientist), one assistant (FN, social science research assist- ant) and one experienced note taker. After giving introductory information and obtaining con- sent from participants, the moderator followed a question guide to explore current relationships between nurses and mothers, the roles and expected roles of each, barriers to good relations and any changes since the workshop series. The discussions continued on each topic until no new information was gained. Table 1: Problems identified by the questionnaire Item Item content 1. Not shown where to wash, cook and use the toilet 2. Ward and toilets not cleaned often enough by staff 3. Mothers expected to clean the ward and toilets themselves 4. Not given enough information about cause of illness 5. Nurses' answers to questions not clear* 6. Staff gave conflicting information* 7. Nurse didn't discuss anxieties or fears* 8. Nurses sometimes talked as if I wasn't there* 9. Not sufficiently involved in decisions about treatment and care* 10. Not always treated with respect and dignity* 11. Not easy to find someone to talk to about concerns* 12. Not clear whom to ask for medical assistance on the ward 13. Nursing staff unavailable when needed on the ward 14. Nursing staff rude/unhelpful when asked for medical assistance on the ward 15. Test results not clearly explained 16. Nurses performed medical tasks poorly 17. Child not told about what was happening when undergoing procedures 18. Staff did not do enough to control pain* 19. Purpose of medicines not explained* 20. Not told about medication side effects* *Indicates taken from PPE-15 Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 5 of 14 (page number not for citation purposes) Discussions were held in Kiswahili and were tape- recorded, with notes taken of verbal and non-verbal responses and as to which participants were speaking. These notes were expanded immediately after each FGD. Data management and analysis Records from workshops and the FGDs were transcribed and translated and then checked by FN. The transcripts and discussion notes were read line by line and coded by CIRC and RNM according to ideas represented in each sec- tion of text. These 'idea codes' were then grouped together as themes using NVivo version 7.0 (QSR International, Cambridge, Massachusetts, United States of America). Themes were discussed within the research team to explore meanings and arrive at a consensus of interpreta- tion of the data. Results We present the proceedings of the workshops, followed by the results of the before-and-after parent questionnaire evaluation and the post-intervention nurse focus-group discussion. Workshops Between 26 and 29 of the 31 nurses scheduled to work on the paediatric ward attended each of the workshops, with roughly equal numbers of trained nurses and nurse attendants. A summary of issues raised at each of the first five workshops is shown in Table 2. During the workshops, nurses acknowledged that they sometimes had a poor relationship with parents of chil- dren on the ward. For example, in the role plays nurses demonstrated that when mothers asked them questions on the ward they might become rude and unhelpful. A nurse role-playing a mother asking when her child's intra- venous line would be attended to elicited as a typical response from other nurses "It is not your job to remind me" and "Wait for the nurses in the next shift". Motivation and respect: ideals and reality In workshop discussions, many nurses described altruism and achieving community respect as reasons for choosing their profession. However, many were disappointed with the reality of their work, often entailing poor relationships with patients and their mothers. "Our working environment is very different from what we expected and this situation contributes to the use of harsh language, hating our job and not working hard" (trained nurse, TN, workshop one, W1). Table 2: Workshop summaries Workshop Summary of responses 1. Why I am a health worker "It was to help my family and the community as a whole" "To give service and comfort to the sick" "I was attracted by the white uniforms, stethoscope and pushing a trolley with medicine" "I wanted to improve health services as it was bad in the areas around us" "It was a good job that was reliable and had more value than others" "It was the only way to get employed" "I wanted to know about different diseases and prevention" 2. How do our clients see us? There is poor cooperation between doctor and nurse. Doctors are our bosses. They do not respect nurse attendants. They want to be attended by nurses in white or by doctors. They feel we don't care because of staff shortages. 3. Women's status in our society Women have fewer educational opportunities. Women often do not know their rights. Women may work harder than men. Men are respected more than women. Women and men may be ignored if they are poor. 4. Unmet women's needs Women need to be empowered through health education. Women need education about their rights in making decisions. Tolerance must be promoted between men and women. 5. Overcoming obstacles at work Low salary Inadequate equipments. No respect between staffs and between patients. Shortage of staffs. Fear of infections. Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 6 of 14 (page number not for citation purposes) Several staff members said that their personal ideals had been replaced by a degree of cynicism towards their work. Many felt this was an inevitable (and to an extent justi- fied) result of the low levels of recognition or reward that they received from their work. This was exemplified in a role play depicting a rich woman arriving at the ward, which led to the following comments by participants: "I was happy seeing my friend. I was aware that there was a patient to attend but my salary is too small. I couldn't even have tea in the morning, so my friend was my hope when I saw her. The poor sick woman had nothing to help me. I had to leave her waiting" (nurse attendant, NA, W1). "A rich person is always served first in the hospital because we expect to get something from her/him. And this is all because the low income makes us easily tempted with small things, like soda" (TN, W1). "The administration does not care for the workers so it turns someone to be irresponsible" (TN, W1). Nurses described feeling undermined by a lack of respect from colleagues, particularly from senior colleagues who were reported to speak harshly to them in front of patients. "Patients ignore me, I get angry, and I give poor service and use bad language, because the doctor has already shown I am not competent" (TN, W3). Nurse attendants also felt undervalued by patients, a feel- ing that was enhanced by their orange uniform (perceived as "non-medical") compared to the white uniform of nurses. "If we help nurses to attend patients, some patients refuse and say 'I want to be attended by a nurse in a white uniform' so there is no trust in us" (NA, W1). "The difference in uniforms results in disrespect between us and patients. When I want to attend him/ her they openly say I want a nurse with a white uni- form. This makes me feel inferior and so instead I will be using harsh words and not giving a quality service" (NA, W5). The superiority of higher cadres of health worker over lower levels was brought out in a role play designed by participants in a workshop to illustrate how this affected the standard of care. Scene 1: A very sick woman enters the ward assisted by a care-taker. She is glanced at by the doctor, who calls for the nurse in charge to show the patient a bed. The nurse in turn glances at the patient and calls for the nurse attendant, currently cleaning the ward, to show the patient to a bed. Scene 2: The doctor listens to the patient's history from the care-taker and calls for the nurse to administer a drip. The nurse calls for the attendant to administer the drip. Nurses reflected that it was often difficult to approach sen- ior staff for clinical advice on patients, as these were likely respond in a dismissive way towards junior staff. Salary and working conditions Low wages and lack of allowances were frequently cited as reasons for low motivation towards work and for giving poor service. "The salary is low. I am not satisfied when I get to work. I only think of how to get money. I ask patients to give me some money so that I give them quality service or I bring things to sell around what I get will help boost my life. So instead of helping the sick I just think of a business to give me income" (TN, W5). "If there was allowance for working long hours I would have been the most hardworking of staff" (TN, W5). In addition to financial and status issues, nurses identified other restrictions in their working environments that led to poor relationships with mothers (Table 3). These included a lack of equipment: "There is not enough equip- ment to make our work good And unavailability of gloves makes attending the patient poor because you can't touch him/her for the fear of disease transmission" (NA, W5), and a perception of unfair decisions made by man- agers: "Some people are promoted and some never get that chance" (TN, W5). Solutions Participants reviewed the discussions from the previous five workshops in a final session designed to stimulate solutions. These are presented in Table 4 and are divided between action points to improve relations with mothers through internal nursing dynamics, and points to improve conditions of work affected by external forces, i.e. hospital administration. A follow-up visit was made six weeks after the last work- shop to find out what action had been taken by the nurses in the study. Researchers were not part of the process of requesting changes at the hospital level, as this might have biased any response from the administration. Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 7 of 14 (page number not for citation purposes) Table 3: Problems leading to poor attitudes towards patients and carers Problem identified by nurses during workshop 5 Average rank of each problem* Respect from colleagues and carers 4.75 Low salary 2.86 Inadequate equipment 1.36 Shortage of staff 1.25 Infection risk 1.25 Working overtime 1.11 No allowances 1.00 Long working hours 0.93 No promotions 0.21 No in-service training 0.07 *All nurses ranked their top five most important problems from 5 (most important) to 1 (least important). The ranks for each problem were summed and divided between the 28 participating nurses. Table 4: Solutions agreed at workshop six Solution action points Implemented by follow-up visit at 6 weeks Improvements internal to nursing group Maintain cooperation • Arrange a meeting with doctors to explain the importance of working together and respect for each other. • Have regular meetings together to maintain respect and address issues. • Meetings had taken place weekly with nurses and doctors, identifying respect as an issue particularly with nursing attendants. Used as a forum for problems with work. Prevent infections • Staff training on disease prevention. • Disseminate education on disease prevention to patients and mothers. • 3/4 nursing staff had attended disease prevention training run by the MoH at the hospital. Respect each other • Be close to fellow staff. • Help each other on job allocation. • Observe punctuality. • Improved assistance between staff was reported, although shortages persisted. Work conscientiously • Be active at work without thinking of low salaries. Improvements via external forces Low salary Request from employer at staff meeting with Regional Administrative Secretary. • Incremental increase agreed to be paid. Allowances • Not agreed. No budget. Shortage of staff • Problem persists. Risk allowance • Not agreed as not in MoH plan. Inadequate equipment • Request taken forward, but no action at this point. Transport for staff • Not agreed. Not allocated in government budget. Staff house • Not affordable for all staff, attributed to government budget. Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 8 of 14 (page number not for citation purposes) At the follow-up visit, nurses reported that the action points had mostly been addressed, although largely with- out the desired outcome. Meetings were reported to have been held among the ward staff to address issues of respect and assistance to colleagues, and some improve- ment was reported. However, the result of the meeting with the Regional Administrative Secretary was less suc- cessful. Many of the issues raised were reported to be in the control of the government rather than the region and therefore could not be addressed locally. Evaluation I: Parent satisfaction In all, 288 parents/guardians participated in the satisfac- tion survey, 144 over a one-week period before the work- shops and another 144 six weeks after the end of the workshops. Demographics of the questionnaire respond- ents were not significantly different in the two surveys: in 95% cases the respondent was the mother; the median age of the respondent was 26 years (IQR 23, 30). The demo- graphics and diagnoses of children were almost identical at the two survey times. The median age of children was 12 months (IQR 7, 24); the median length of stay at the time of interview was three days (IQR 1,4); 38% children were diagnosed with malaria, 33% with diarrhoea and 22% with pneumonia. Cronbach's coefficient was high, at 0.85 for the baseline questionnaire and 0.77 for the post-intervention ques- tionnaire, suggesting that variation in scores is more likely to be due to variation in true differences rather than meas- urement error. Validity testing by means of the discrimi- nance method suggested that the questionnaire was valid; for example, mothers who reported having to clean the ward or toilets themselves were statistically significantly more likely to cite problems (p < 0.001 for both surveys). Analysis of parent satisfaction questionnaires showed fre- quent problems reported both before and after the inter- vention (Table 5). Overall, the mean percentage of mothers reporting each of 20 problems was not statisti- cally significantly different after the intervention, com- pared to before it (38.9% versus 41.2%). However, the number of problems reported by individual mothers did decrease overall, with a shift in this distribution to the left (Figure 1). Analysis of specific components of the satisfaction ques- tionnaire found some improvements, although some stayed the same and some aspects appeared to worsen (Table 5, Table 6). The items with the most statistically significant improvement were those that measured the responsiveness of the nurses, for example in discussing anxieties (problem for 45% mothers fell to 10%), being able to find someone to talk to about concerns (problem for 42% fell to 14%), telling the child about his or her pro- cedures (problem for 35% fell to 22%), and, more techni- cally, being more careful when performing medical tasks such as injections and taking blood (problem for 31% fell to 17%). Improvements were also made in aspects of role defini- tion: mothers were more likely to have been shown where to wash, cook and use the toilet (problem for 68% fell to 56%) and had fewer problems with knowing whom to ask for assistance on the ward (22% fell to 13%). Fewer moth- ers reported problems with receiving conflicting informa- tion (18% fell to 4%) but more mothers reported that they had not been given enough information about the cause of illness (51% rose to 64%). In addition, attitudes of nurses towards mothers did not appear to have improved: mothers reported nurses talking as if they weren't there (31% rose to 62%) and being rude or unhelpful when asked for medical assistance on the ward more often (37% rose to 53%); the proportion reporting being treated with respect and dignity did not increase (21% before and 19% after). Evaluation II: Follow-up FGD with nurses and attendants During the workshops we noticed differences in opinions and some tension between nursing attendants and trained nurses. We therefore conducted evaluative FGDs with each of these groups separately, six months after the last follow-up visit. All nurses still working on the paediatric ward (30) were invited, and 24 accepted, 15 for the nurse attendants' FGD and nine for the trained nurses' FGD. The nurse attendants were younger, between 28 and 57 years, while trained nurses were aged between 41 and 58 years. Attitude change The response to the workshops was overwhelmingly pos- itive among both nursing attendants (NA) and trained nurses (TN), although barriers to good relationships between staff and between staff and patients remained. Participants reported taking on a more positive attitude towards work, and empathizing more with mothers. NA08 "After the workshop there is no laziness. For example when a child arrives seriously sick, I take the tests to the laboratory and ask them to work on it fast so that I can go and give the child medication. The seminar has helped us to change and to work hard". TN01 "For us as nurses, the workshops we did helped us as we now have a close relationship with our cli- ents, we have increased love to them, we have time to listen to their complaints. The workshop helped us to correct ourselves [kujirekebisha]". Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 9 of 14 (page number not for citation purposes) Table 5: Dichotomous problem score results before and after the intervention Item Item content % reported as a problem: Baseline N % reported as a problem: Post Workshop n z-test p-value 1. Not shown where to wash, cook and use the toilet. 67.8 143 55.6 144 0.032 2. Ward and toilets not cleaned often enough by staff. 27.8 144 22.9 144 0.343 3. Mothers expected to clean the ward and toilets themselves. 31.7 142 35.4 144 0.515 4. Not given enough information about cause of illness. 51.4 144 63.9 144 0.032 5. Nurses' answers to questions not clear. 29.2 144 30.6 144 0.797 6. Staff gave conflicting information. 18.1 144 3.5 144 < 0.001 7. Nurse didn't discuss anxieties or fears. 45.1 144 9.7 144 < 0.001 8. Nurses sometimes talked as if I wasn't there. 31.0 142 61.8 144 < 0.001 9. Not sufficiently involved in decisions about treatment and care. 96.5 144 99.3 144 0.099 10. Not always treated with respect and dignity. 21.0 143 19.4 144 0.746 11. Not easy to find someone to talk to about concerns. 42.4 144 13.9 144 < 0.001 12. Not clear who to ask for medical assistance on the ward. 21.5 144 13.2 144 0.062 13. Nursing staff unavailable when needed on the ward. 27.8 144 31.3 144 0.518 14. Nursing staff rude/unhelpful when asked for medical assistance on ward. 36.8 144 54.2 144 < 0.001 15. Test results not clearly explained. 45.8 144 38.2 144 0.189 16. Nurses performed medical tasks poorly. 30.6 144 16.7 144 0.006 17. Child not told about what was happening when undergoing procedures. 35.4 144 22.2 144 0.013 18. Staff did not do enough to control pain. 44.1 102 41.7 127 0.717 19. Purpose of medicines not explained. 47.1 138 56.3 144 0.124 20. Not told about medication side effects. 75.7 144 88.9 144 0.003 21. Mean of all questions 41.2 144 38.9 144 0.690 Human Resources for Health 2009, 7:50 http://www.human-resources-health.com/content/7/1/50 Page 10 of 14 (page number not for citation purposes) Number of problems reported at (a) the baseline survey and (b) the post-intervention surveyFigure 1 Number of problems reported at (a) the baseline survey and (b) the post-intervention survey. 0 5 10 15 20 Number of parents 0 5 10 15 Number of problems reported 0 5 10 15 20 Number of parents 0 5 10 15 20 Number of problems reported (a) (b) Table 6: Questions showing better, worse and the same responses Problem level reduced (i.e. improvement) Problem level increased (i.e. worse) Problem level stayed same Not shown where to wash, cook, toilet Not given enough info about cause of illness Ward and toilets not cleaned by staff Staff gave conflicting information Nurses sometimes talked as if I wasn't there Mothers expected to clean the ward and toilets themselves Nurse didn't discuss anxieties or fears Nursing staff unhelpful when asked for medical assistance on the ward Nurses' answers to questions not clear Not easy to find someone to talk to about concerns Not told about medication side effects Not sufficiently involved in decisions about treatment and care Not clear who to ask for medical assistance on the ward Not always treated with respect and dignity Nurses performed medical tasks poorly Nursing staff unavailable when needed on the ward Child not told what was happening when undergoing procedures Test results not clearly explained Staff did not do enough to control pain Purpose of medicines not explained [...]... nurses in the study, and to the data management team at the Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Moshi, Tanzania Page 13 of 14 (page number not for citation purposes) Human Resources for Health 2009, 7:50 Ethical approval was granted by review boards of the National Institute of Medical Research, Tanzania, and the London School of Hygiene & Tropical Medicine, London, United Kingdom... progress, and both nursing assistants and trained nurses feared raising the topic again As a result they asked the research team to present their views to managers Facilitator: "Are there any other questions? I am finished from my side." NA01: "There is a question and that is: How are you going to help us with this issue of low salary?" NA05: "Doctor, I have an addition to that: those who are working... 1):1-6 Fonn S, Xaba M: Health Workers for Change, a Manual to Improve Quality of Care In Women's Health Project and TDR/ WHO (TDR/GEN/1952) Geneva: World Health Organisation; 1995 Fonn S, Mtonga AS, Nkoloma HC, Bantebya Kyomuhendo G, daSilva L, Kazilimani E, Davis S, Dia R: Health providers' opinions on provider-client relations: results of a multi-country study to test Health Workers for Change Health... Policy Plan 2001, 16(Suppl 1):19-23 Onyango-Ouma W, Laisser R, Mbilima M, Araoye M, Pittman P, Agyepong I, Zakari M, Fonn S, Tanner M, Vlassoff C: An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool Health Policy Plan 2001, 16(Suppl 1):24-32 Reyburn H, Mwakasungula E, Chonya S, Mtei F, Bygbjerg I, Poulsen A, Olomi R: Clinical assessment and... treatment in paediatric wards in the north-east of the United Republic of Tanzania Bull World Health Organ 2008, 86:132-139 Mwangi R, Chandler C, Nasuwa F, Mbakilwa H, Poulsen A, Bygbjerg IC, Reyburn H: Perceptions of mothers and hospital staff of paediatric care in 13 public hospitals in northern Tanzania Trans R Soc Trop Med Hyg 2008, 102:805-810 Picker Institute: Implentation manual Boston, MA:... participatory research approach to improve relationships between nursing staff and parents or guardians of patients on the paediatric ward of a busy regional hospital in Tanzania had limited success Overall, improvements were made in the responsiveness of nursing staff to the needs of mothers, but the majority of the factors identified during the workshops as hindering positive relationships remained after the... the interpretation of the data and to drafting the manuscript All authors read and approved the final manuscript Acknowledgements We surmise that increased responsiveness from the hospital administration, and the health sector more broadly, to the needs of existing nursing staff is needed before The authors are grateful for the support of the hospital administration and participation of the nurses... counties: a critical review of experience and lack of experience In Presented at the International Conference on Improving Use of Medicines Chiang Mai, Thailand; 1997 Howie SR, Hill SE, Peel D, Sanneh M, Njie M, Hill PC, Mulholland K, Adegbola RA: Beyond good intentions: lessons on equipment donation from an African hospital Bull World Health Organ 2008, 86:52-56 Le Grand J: Motivation, Agency, and Public... Preferential treatment for certain patient groups exemplifies this, and our finding of differential treatment for richer clients echoes findings about nurses in another hospital setting in Ghana [28] In addition, "can do" began to be seen as more complex than knowledge and equipment: the importance of relationships between staff and between staff and communities [29], and organizations' role in managing... supervision, answerable to cases that might occur The government should think of us getting night allowance It is our right – we don't work as Samaritans we want payments This should be improved" Discussion Tanzania's Health Sector Strategic Plan of 2003–2008 has focused reforms towards the delivery of good-quality health services and meeting clients' satisfaction [23] This study found that a participatory . Change, on nurse-parent relationships on a paediatric ward in a busy regional hospital in Tanza- nia. The evaluation used before-and-after questionnaires with parents/guardians and two after -intervention. Kilimanjaro Christian Medical Centre, Moshi, Tanzania, 2 Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, 3 Department of Infectious and Tropical Diseases, London. relationships on a Tanzanian paediatric ward Rachel N Manongi 1 , Fortunata R Nasuwa 2 , Rose Mwangi 2 , Hugh Reyburn 2,3 , Anja Poulsen 2,4 and Clare IR Chandler* 3 Address: 1 Community Health Department,